Examining Real-World Therapy Practice of Cognitive Screening and Assessment in Post-Acute Care

Published:December 13, 2022DOI:



      Routine implementation of cognitive screening and assessment by therapy providers in post-acute settings may promote improved care coordination. This study examined the frequency of cognitive screening and assessment documentation across post-acute settings, as well as its relationship with contextual factors and outcomes.


      Cross-sectional observational study using Medicare claims and electronic health record data from 1 large health system.

      Setting and Participants

      Older adults admitted to post-acute care after an acute hospitalization.


      Descriptive analysis examined documentation of cognitive screening and assessment. Logistic and hierarchical linear regression evaluated the relationship among patient factors, cognitive screening and assessment, and patient outcomes.


      The most common admission diagnoses for the final sample (n=2535) were total hip or knee joint replacement (41.7%) and stroke (15.3%). Following acute hospitalization, patients were discharged to inpatient rehabilitation (22.6%), skilled nursing (9.3%), or home health (68.1%). During the post-acute care stay, 38% of patients had documentation of cognitive screening by any therapy discipline. Patterns of documentation varied across disciplines and post-acute settings. Documentation of standardized cognitive assessments was limited, occurring for less than 2% of patients. Admission for stroke was associated with significantly higher odds of cognitive screening or assessment [odds ratio (OR) 2.07, 95% CI 1.13, 3.82] compared to patients with other diagnoses. There was no significant relationship between documentation of cognitive screening or assessment and 30-day readmissions (OR 0.81, 95% CI 0.53, 1.28).

      Conclusion and Implications

      The key finding was inconsistent documentation of cognitive screening and assessment across disciplines and post-acute settings, which could be in part due to variation in electronic health record platforms. Future work can expand on these results to understand the degree to which contextual factors facilitate or inhibit routine delivery and documentation of cognitive screening and assessment. Findings can support implementation of standardized data elements to lead to improved care coordination and outcomes.


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        • Joray S.
        • Wietlisbach V.
        • Büla C.J.
        Cognitive impairment in elderly medical inpatients: detection and associated six-month outcomes.
        Am J Geriatr Psychiatr. 2004; 12: 639-647
        • Amini R.
        • Kawser B.
        Impact of the interaction between mild and mild-to-moderate cognitive impairment with chronic health problems on hospital admission among community-dwelling older adults.
        Geriatr Gerontol Int. 2020; 20: 1213-1220
        • Buslovich S.
        • Kennedy G.J.
        Potential Effect of Screening for Subtle Cognitive Deficits on Hospital Readmission.
        J Am Geriatr Soc. 2012; 60: 1980-1981
        • Virani S.S.
        • Alonso A.
        • Benjamin E.J.
        • et al.
        Heart disease and stroke statistics—2020 update: a report from the American Heart Association.
        Circulation. 2020; 141: e139-e596
        • Centers for Medicare and Medicaid Services
        Nursing Home Data.
        Compendium 2015 Edition, 2015
        • Callahan K.E.
        • Lovato J.F.
        • Miller M.E.
        • et al.
        Associations between mild cognitive impairment and hospitalization and readmission.
        J Am Geriatr Soc. 2015; 63: 1880-1885
        • Stewart R.
        • Richards M.
        • Brayne C.
        • et al.
        Vascular Risk and Cognitive Impairment in an Older, British, African-Caribbean Population.
        J Am Geriatr Soc. 2001; 49: 263-269
        • Donabedian A.
        The seven pillars of quality.
        Arch path Lab Med. 1990; 114: 1115-1118
        • Linkens A.E.M.J.H.
        • Milosevic V.
        • van der Kuy P.H.M.
        • et al.
        Medication-related hospital admissions and readmissions in older patients: an overview of literature.
        Int J Clin Pharm. 2020; : 1-9
        • Petry H.
        • Ernst J.
        • Steinbrüchel-Boesch C.
        • et al.
        The acute care experience of older persons with cognitive impairment and their families: A qualitative study.
        Int J Nurs Stud. 2019; 96: 44-52
        • Rochette A.D.
        • Alexander N.B.
        • Cigolle C.T.
        • et al.
        Cognitive status as a robust predictor of repeat falls in older Veterans in post-acute care.
        Aging Clin Exp Res. 2020; : 1-6
        • Burgdorf J.G.
        • Amjad H.
        • Bowles K.H.
        Cognitive impairment associated with greater care intensity during home health care.
        Alzheimer's & Dementia, 2021
        • Zhang Z.
        • Hayward M.D.
        • Yu Y.L.
        Life course pathways to racial disparities in cognitive impairment among older Americans.
        J Health Soc Behav. 2016; 57: 184-199
        • Chase J.A.D.
        • Russell D.
        • Huang L.
        • et al.
        Relationships between race/ethnicity and health care utilization among older post-acute home health care patients.
        J Appl Gerontol. 2020; 39: 201-213
        • Goodman D.C.
        • Fisher E.S.
        • Chang C.H.
        After hospitalization: A Dartmouth atlas report on post-acute care for Medicare beneficiaries.
        The Dartmouth Institute, 2011: 56
        • Rao V.U.
        • Chugh A.R.
        • Stark K.
        • et al.
        Influence of a Novel Multidisciplinary Cognitive Impairment Intervention on Post-Acute Care in an Inpatient Community-Based HFrEF Cohort.
        J Card Fail. 2019; 25: S60
        • Resnick B.
        • Beaupre L.
        • McGilton K.S.
        • et al.
        Rehabilitation interventions for older individuals with cognitive impairment post-hip fracture: a systematic review.
        J Am Med Dir Assoc. 2016; 17: 200-205
        • Cicerone K.D.
        • Goldin Y.
        • Ganci K.
        • et al.
        Evidence-based cognitive rehabilitation: systematic review of the literature from 2009 through 2014.
        Arch phys Med Rehabil. 2019; 100: 1515-1533
        • Giles G.M.
        • Edwards D.F.
        • Morrison M.T.
        • et al.
        Screening for functional cognition in postacute care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014.
        Am J Occup Ther. 2017; 71 (:7105090010p1-7105090010p6)
        • Rouch S.A.
        • Skidmore E.R.
        • Leland N.E.
        AOTA Quality Project: Characterizing contemporary practice to inform quality measure development: Findings from Phase II.
        University of Pittsburgh: Unversity of Pittsburgh, 2020
        • Giles G.M.
        • Edwards D.F.
        • Baum C.
        • et al.
        Making Functional Cognition a Professional Priority.
        Am J Occup Ther. 2020; 74 (:7401090010p1-7401090010p6)
        • Ganz D.A.
        • Almeida S.
        • Roth C.P.
        • et al.
        Can structured data fields accurately measure quality of care? The example of falls.
        J Rehabil Res Dev. 2012; 49: 1411
        • Doubova S.V.
        • Lamadrid-Figueroa H.
        • Pérez-Cuevas R.
        Use of electronic health records to evaluate the quality of care for hypertensive patients in Mexican family medicine clinics.
        J Hypertens. 2013; 31: 1714-1723
        • Baker D.W.
        • Persell S.D.
        • Thompson J.A.
        • et al.
        Automated review of electronic health records to assess quality of care for outpatients with heart failure.
        Ann Intern Med. 2007; 146: 270-277
        • Santry H.P.
        • Strassels S.A.
        • Ingraham A.M.
        • et al.
        Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach.
        BMC Med Res Methodol. 2020; 20: 1-19
        • Carayon P.
        • Wetterneck T.B.
        • Rivera-Rodriguez A.J.
        • et al.
        Human factors systems approach to healthcare quality and patient safety.
        Appl Ergon. 2014; 45: 14-25
        • Darin-Mattsson A.
        • Fors S.
        • Kåreholt I.
        Different indicators of socioeconomic status and their relative importance as determinants of health in old age.
        Int J Equity Health. 2017; 16: 1-11
        • Virapongse A.
        • Misky G.J.
        Self-identified social determinants of health during transitions of care in the medically underserved: a narrative review.
        J Gen Intern Med. 2018; 33: 1959-1967
        • U.S. Census Bureau
        U.S. Census Bureau, editor.
        Date: 2017
        Date accessed: January 19, 2023
        • Tian W.
        An all-payer view of hospital discharge to postacute care.
        Statistical Brief# 205, 2013: 2016
        • Donabedian A.
        Evaluating the quality of medical care.
        Milbank Mem Fund Q. 1966; 44: 166-206
        • Reisberg B.
        • Ferris S.H.
        • de Leon M.J.
        • et al.
        The Global Deterioration Scale for assessment of primary degenerative dementia.
        Am J Psychiatr. 1982;
        • Baum C.M.
        • Connor L.T.
        • Morrison T.
        • et al.
        Executive function performance test.
        Am J Occup Ther. 2013;
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Nasreddine Z.S.
        • Phillips N.A.
        • Bédirian V.
        • et al.
        The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
        J Am Geriatr Soc. 2005; 53: 695-699
        • Rogers J.
        Performance assessment of self-care skills.
        Rehabil Psychol. 1989;
        • Tariq S.H.
        • Tumosa N.
        • Chibnall J.T.
        • et al.
        Comparison of the Saint Louis University Mental Status Examination and the Mini-Mental State Examination for Detecting Dementia and Mild Neurocognitive Disorder—A Pilot Study.
        Am J Geriatr Psychiatr. 2006; 14: 900-910
        • Austin S.R.
        • Wong Y.-N.
        • Uzzo R.G.
        • et al.
        Why summary comorbidity measures such as the Charlson comorbidity index and Elixhauser score work.
        Med Care. 2015; 53: e65
        • Weech-Maldonado R.
        • Lord J.
        • Pradhan R.
        • et al.
        High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance.
        Inquiry. 2019; 56 (:46958018825061-46958018825061)
        • Weech-Maldonado R.
        • Neff G.
        • Mor V.
        Does quality of care lead to better financial performance?: the case of the nursing home industry.
        Health Care Manage Rev. 2003; 28: 201-216
        • Kiernan K.
        Insights into using the GLIMMIX procedure to model categorical outcomes with random effects. 2179. Paper, 2018: 8-11
        • McMullen T.L.
        • Mandl S.R.
        • Pratt M.J.
        • et al.
        The IMPACT Act of 2014: Standardizing patient assessment data to support care coordination, quality outcomes, and interoperability.
        J Am Geriatr Soc. 2022; 70: 975-980
        • Shier V.
        • Edelen M.O.
        • McMullen T.L.
        • et al.
        Standardized assessment of cognitive function of post-acute care patients.
        J Am Geriatr Soc. 2022; 70: 1001-1011
        • D'Souza C.E.
        • Greenway M.R.F.
        • Graff-Radford J.
        • et al.
        Cognitive Impairment in Patients with Stroke.
        in: Seminars in neurology. Thieme Medical Publishers, Inc, 2021
        • Rait G.
        • Fletcher A.
        • Smeeth L.
        • et al.
        Prevalence of cognitive impairment: results from the MRC trial of assessment and management of older people in the community.
        Age Ageing. 2005; 34: 242-248
        • Kitsis P.
        • Zisimou T.
        • Gkiatas I.
        • et al.
        Postoperative Delirium and Postoperative Cognitive Dysfunction in Patients with Elective Hip or Knee Arthroplasty: A Narrative Review of the Literature.
        Life. 2022; 12: 314
        • MedPAC
        Section 2: Medicare beneficiary demographics.
        in: A Data Book: Health care spending and the Medicare program. 2020
        • Chan K.S.
        • Fowles J.B.
        • Weiner J.P.
        Review: Electronic Health Records and the Reliability and Validity of Quality Measures: A Review of the Literature.
        Medical Care Research and Review. 2010; 67: 503-527
        • Lazar E.J.
        • Fleischut P.
        • Regan B.K.
        Quality Measurement in Healthcare.
        Annu Rev Med. 2013; 64: 485-496
        • Cheng E.M.
        • Sanders A.E.
        • Cohen A.B.
        • et al.
        Quality measurement. It's here to stay.
        Neurol Clin Pract. 2014; 4: 441-446